- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.32 / $542.48 / $2,273.00
| Professional | | $372.32 | $542.48 | $2,273.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,161.52 / $4,161.52 / $5,329.68
| Facility | | $4,161.52 | $4,161.52 | $5,329.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.64 / $713.92 / $2,008.12
| Professional | | $605.64 | $713.92 | $2,008.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.15 / $807.02 / $2,008.12
| Professional | | $434.15 | $807.02 | $2,008.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.20 / $807.02 / $2,008.12
| Professional | | $552.20 | $807.02 | $2,008.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $563.57 / $774.63 / $2,464.73
| Professional | | $563.57 | $774.63 | $2,464.73 |